Healthcare Provider Details

I. General information

NPI: 1902366412
Provider Name (Legal Business Name): JENNIFER CRYSTAL BIESIADECKI DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 HOSPITAL DR
WINAMAC IN
46996-1173
US

IV. Provider business mailing address

1037 DES PLAINES AVE APT 507
FOREST PARK IL
60130-2152
US

V. Phone/Fax

Practice location:
  • Phone: 574-946-2194
  • Fax:
Mailing address:
  • Phone: 815-508-9320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02006838A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: